More Discussion on Sleep: Relationship between Organs and Insomnia

It is normal to lose some sleep in the morning as we age because there is a natural Qi and Blood decline as we grow old. We are also likely to fall asleep earlier in these cases so the amount of time that we are asleep for may not drastically change. But some of us actually develop a sleep issue at some point in our lifetime. Perhaps others already have had one for a long time. When we talk about insomnia, we are talking about various manifestations, not just one. Insomnia can manifest as restless sleep (shallow sleep), excessive dreaming, difficulty falling asleep, waking frequently during the night, and difficulty going back to sleep after waking up at night or early in the morning, all of which can result in not feeling refreshed and rested in the morning. In this post, we will discuss insomnia pathologies from the TCM perspective.

Before going into details of TCM explanation, we will briefly discuss how insomnia pathology is explained in Western medicine. Other than cases where sleep disturbance is secondary to another condition such as pain which makes it uncomfortable to sleep or nocturia which wakes one up frequently to go to the washroom, insomnia pathophysiology is quite complex and still inconclusive. This is because multiple factors are involved, from genetic/hereditary vulnerability to insomnia, precipitating events or stressors and moderators, to varied abnormal neurobiological processes. These abnormal neurobiological processes include simultaneous activation of wake- and sleep-promoting areas in the brain, reduced secretion of gamma-aminobutyric acid (GABA, an inhibitory neurotransmitter that helps to transition our body from sympathetic mode to parasympathetic mode), abnormal brain morphometry (i.e. size, volume, and shape characteristics of different brain structures and specific tissues does not appear what they should be during sleep), and process S&C misalignment (where process S is the sleep-wake homeostasis that acts like a timer which hikes up our sleep drive after a certain amount of time awake due to accumulation of sleep-inducing substances in the brain, and process C is the circadian process that regulates the daily rhythm/timing of the sleep in coordination with the light-dark cycle of day and night). These processes result in hyperarousal of the brain therefore requiring more effort and intention to sleep.

There can be various TCM syndromes for insomnia and they are mostly based on organ differentiation diagnosis. Organs that are associated with insomnia are the Heart, Liver, Stomach, Kidney, and Gallbladder. Insomnia results from disturbance to our spirit in one way or another. While there are five types of spirits in TCM, two of them, the Hun (Ethereal Soul) and Shen (Mind) are particularly associated with sleep. Hun resides in the Liver while Shen resides in the Heart. While Hun can give freedom, inspiration, and ideas to Shen by its nature of moving freely, if it is too active, it can cause unsound sleep. Shen is the opposite of Hun in nature and can control Hun by its rooting and steadying ability. Hun anchors to the Liver Blood and it is important that we have sufficient Liver Blood and Yin to house the Hun. When they are very deficient, Hun may leave the body temporarily during sleep or just before falling asleep. With Liver Blood Deficiency, we may have difficulty falling asleep but also additional symptoms like dizziness, blurred vision, dry skin, brittle nails, and scanty menses. The same applies to the Heart Blood. Shen anchors to the Heart Blood. Sufficient Heart Blood will house the Shen and make the sleep comfortable. However, when Heart Blood is deficient, it may be difficult to fall asleep initially even though sleep may be sound afterwards. Because Shen also governs other mental activities such as emotions, consciousness, thinking, and memory, insomnia associated with Heart Blood Deficiency failing to house Shen can often accompany symptoms like emotional problems like dementia/anxiety/restlessness, poor memory, slow thinking, and even unconsciousness. When Yin is deficient (of either Liver or Heart) past just Blood Deficiency, there can be frequent wakings during the night in addition to difficulty falling asleep.

Gallbladder is an organ that commonly accompanies Heart and Liver for pathologies (e.g. Gallbladder Qi Deficiency commonly accompanies Heart Qi Deficiency). Gallbladder has an effect on our personality (e.g. controls decisiveness, initiative, and courage) as well as the quality and length of sleep. When we have Gallbladder Deficiency, we may wake up early in the morning without external stimulus and fail to fall asleep again afterwards. Its Deficiency can also lead to excessive dreams that are unpleasant such as those of fights, trials, and suicides.

A common cause of insomnia regardless of which organ or the layer it is present in, is the presence of a Heat pathogen (e.g. Heat, Fire, Phlegm-Fire, Exterior Wind-Heat, etc.). Heat has a nature to rise (think about convection) and therefore usually comes up to the Heart to disturb our Shen. This Heat can be of external origin, internal origin, excess, or deficient in nature. Heat disturbing our Shen results in excessive dreams as well as difficulty staying asleep more so than difficulty falling asleep. When we say excessive dreams, it also has a comprehensive definition as it includes unpleasant feelings or restlessness upon waking up, nightmares, recurrent dreams, and wandering/moving in dreams. While normally everyone has dreams every night, they are not remembered. If they can be remembered, the dream was likely excessive.  

Eating late at night can also cause unsound sleep because the Spleen and Stomach need to work on digestion. This means that the body cannot relax fully at night. When there is food retention in the Stomach, it can specifically cause restless sleep with dreams. At the same time, we should note that eating late at night, which is a time of Yin, forces the Stomach to use its Yin energy and in the long run, such behaviour leads to Stomach Yin deficiency.

Kidney Yin Def can lead to Heart Yin Deficiency as Kidney Yin is the source Yin for all other organs. Kidney Yin Def and Heart Yin Deficiency create a common pattern called Kidney and Heart Disharmony with Empty Heat. According to the Five Elements theory, the Kidney corresponds to Water and the Heart corresponds to Fire. Under normal conditions, the Heart Fire needs to go down to the Kidneys while the Kidney Water should be pumped up to the Heart. When this is achieved, we can have a sound sleep at night. However, when Yin is deficient in these organs, we get an empty/deficient Heat (which comes from the relative excess of Yang) that disturbs the Shen on top of the difficulty in housing the Shen due to Yin Deficiency. Then there can be insomnia with very restless sleep in addition to other symptoms like palpitation with anxiety, forgetfulness, and night sweats.   

While having these patterns will require a formal treatment with the use of relevant acupoints and herbs that correct the specific imbalance, common acupuncture points that we can generally benefit from regardless of the pattern are An Mian, Shen Men (HT7), and San Yin Jiao (SP6). Try firmly pressing and massaging these points at times when sleep is difficult. All of these points are located bilaterally in our body. An Mian is located behind the mastoid process (see picture below).  Shen Men is located along the wrist crease in the depression on the radial side (side that is closer to the thumb) of the flexor carpi ulnaris tendon (see picture below). Alternatively, this point can be reached by massaging deeply into the depression on the ulnar side (side close to the pinky finger) of the same tendon. Lastly, San Yin Jiao is located about one handbreadth (or the distance from the bottom of the foot to the medial malleolus) above the tip (protruding point) of the medial malleolus right behind the border of the tibia (see picture below).